Technology Holds Potential To Change Surgical Trends
Meanwhile, INSIGHTEC is exploring a much bigger canvas. The company has identified over a hundred different diseases that it could target with its Exablate Neuro technology, says Ferré.
“The trend is to try to treat diseases earlier in their cycle,” he says, adding that focused ultrasound treatment may become a tool in this regard. In addition, “This technology, as a platform, has the capabilities of transforming the way we look at surgery. If you look at the trends of surgeries, you’ve seen it go from open surgery, to laparoscopic surgery, to robotic surgery. We think we’re now the next generationincisionless surgery which is completely noninvasive.”
Mandy Roth is the innovations editor at HealthLeaders.
The Facts About Parkinsons Disease
Parkinson’s disease is a progressive neurogenerative disease that causes nerve cells in the area of the brain that controls movement to weaken and/or die. While healthy neurons produce a chemical called dopamine, which the brain needs a certain amount of in order to regulate movement, weakened neurons produce lower levels of dopamine. What causes these neurons to weaken is currently unknown.
Some patients with Parkinson’s disease also suffer from a decline in norepinephrine, a chemical that transmits signals across nerve endings and controls various functions, such as blood pressure and heart rate.
More than 10 million people worldwide are currently living with Parkinson’s disease and nearly one million will be living with the disease in the United States this year, according to the Parkinson’s Foundation.
Surgical Therapies With Transplantation And Gene Therapy
Cell transplantation is regarded as a potential future PD treatment. There have been trials using autologous and non-autologous cells. Human embryonic stem cells and induced pluripotent stem cells are few of the cells that have been included in these transplantation studies. One of the concerns with cell transplantation using stem cells is the ethical bounds that must be considered.
Since the first clinical trial in 1987 involving the transplantation of dopaminergic- neuron-rich human fetal mesencephalic tissue into PD patients striatums, more research has aimed to explore whether the grafted dopaminergic neurons will live and form connections in the brain, if the patients brain can harmonize and make use of the grafted neurons, and if the grafts can generate significant clinical improvement. Clinical trials with cell therapy intend to discover if there are long-lasting improvements following restoration of striatal DA transmission by grafted dopaminergic neurons. Experimental data from rodents and nonhuman primates show that fetal ventral mesencephalon intrastriatal grafted DA neurons demonstrate many morphological and functional characteristics of normal DA neurons. Significant improvements of PD-like symptoms in animal models have been demonstrated after successful reinnervation by the grafts. Dopaminergic grafts can reinnervate the striatum in the brain, restore regulated release of DA in the striatum, and can become functionally integrated into neural circuitries.
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What Is Parkinson’s Disease
Parkinsons disease occurs when brain cells that make dopamine, a chemical that coordinates movement, stop working or die. Because PD can cause tremor, slowness, stiffness, and walking and balance problems, it is called a movement disorder. But constipation, depression, memory problems and other non-movement symptoms also can be part of Parkinsons. PD is a lifelong and progressive disease, which means that symptoms slowly worsen over time.
The experience of living with Parkinson’s over the course of a lifetime is unique to each person. As symptoms and progression vary from person to person, neither you nor your doctor can predict which symptoms you will get, when you will get them or how severe they will be. Even though broad paths of similarity are observed among individuals with PD as the disease progresses, there is no guarantee you will experience what you see in others.
Parkinsons affects nearly 1 million people in the United States and more than 6 million people worldwide.
For an in-depth guide to navigating Parkinsons disease and living well as the disease progresses, check out our Parkinsons 360 toolkit.
What Is Parkinson’s Disease?
Dr. Rachel Dolhun, a movement disorder specialist and vice president of medical communications at The Michael J. Fox Foundation, breaks down the basics of Parkinson’s.
What Are The Treatment Options For Tremor In Patients With Parkinson Disease
Levodopa/carbidopa, dopamine agonists, and anticholinergics each provide good benefit for tremor in approximately 50-60% of patients. If a patient is experiencing troublesome tremor and if symptoms are not controlled adequately with one medication, another should be tried. If the tremor is not controlled adequately with medication, surgical therapy may be considered at any time during the disease.
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Collections Of Csf And Serum
In total, 3 ml CSF and 2 ml venous whole blood was collected in polypropylene tubes at 07:00 to 10:00 in the fasting condition, with anti-parkinsonian medication withdrawal for 1214 h if patients condition permitted . CSF and serum samples were centrifuged immediately at 3000 rpm at 4°C. Approximately 0.5 ml volume of the supernatant of CSF and serum were put into separate Nunc cryotubes and frozen at -80°C. Freezing and thawing and protein degradation were carefully avoided.
Limitations Side Effects And Long
Baltuch cautions, however, that focused ultrasound thalamotomy is not without risk or side effects, there are limitations, and there are not yet long-term studies.
- Side effects: Side effects include difficulty walking or unsteadiness following the procedure, along with tingling or numbness in the lips or fingers. Most issues resolve within months.
- Limitations: Currently, only one side of the body can be treated. Earlier forms of surgical ablation sometimes resulted in speech difficulties, so for now, the FDA has limited treatment to one side of the brain. The side that controls the patient’s dominant hand is usually targeted. INSIGHTEC is exploring bilateral treatment in medical centers outside the U.S. In addition, while treatment can reduce or eliminate tremors on one side of the body, it does not stop other symptoms of Parkinson’s or slow disease progression.
- Long-term studies: Because five- and 10-year studies have not yet been conducted, “We dont yet long-term effectiveness” of focused ultrasound thalamotomy for tremor-dominant Parkinson’s and essential tremor, says Baltuch. “The published data show that this may not be as effective in tremor reduction as, potentially, deep brain stimulation can. And, although it’s non-invasive, you’re still making a thermal lesion .”
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Tremor Response To Dopaminergic Therapy
In the 38 patients with rest tremor amplitude > 0 who had both ON and OFF medication assessments at follow-up and were treated with either levodopa or a dopamine agonist alone, we found a significant direct association between the raphe/putamen 123I-FP-CIT binding ratio and the percentage improvement in rest tremor amplitude . Higher ratios, suggestive of more severe putaminal degeneration compared to raphe involvement, correlate with bigger improvements of tremor following acute dopamine replacement therapy, while lower ratios, suggestive of relatively greater raphe involvement associated with less severe putaminal degeneration, correlate with smaller therapeutic responses .
Raphe/putamen ratio association with the rest tremor amplitude percentage improvement. Scatter plot showing raphe/putamen 123I-FP-CIT uptake ratio of 38 patients plotted against their respective percentage rest tremor amplitude improvement. Line of best fit is shown. Patients taking levodopa only are represented by a green dot patients taking a dopamine agonist only are represented by a blue square. The raphe/putamen ratio is associated with the percentage improvement of rest tremor amplitude .
Symptoms Of Parkinson’s Disease
These common symptoms of Parkinson’s disease often begin gradually and progress over time:
- Shaking or tremor
- Poor posture
- Slowing of body movements
As the disease continues to progress, additional symptoms can occur such as slurred or soft speech, trouble chewing and/or swallowing, memory loss, constipation, trouble sleeping, loss of bladder control, anxiety, depression, inability to regulate body temperature, sexual dysfunction, decreased ability to smell, restless legs and muscle cramps.
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Classification Of Motor Phenotypes For Pd Patients
Motor symptoms were assessed by the Unified Parkinsons Disease Rating Scale III. Motor phenotypes were identified based on the ratio of mean tremor score to the mean bradykinesia/rigid score . Patients with a ratio greater than 1.0, less than 0.80, and between 0.80 and 1.0 were classified into PD-TD, PD-PIGD, and mixed-types , respectively. The patients of mixed-type were excluded due to the mixed motor phenotype.
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Treatment Delivers Immediate Results
When the process is complete, tremors on the treated side of the body often completely disappear.
An online video demonstrates Baltuch performing the procedure on a patient with essential tremor. Before treatment the patient tries to bring a cup of water to his mouth, but his tremors prevent him from doing do. After the procedure, he is shown touching the tips of his two index fingers together, remarking, “I couldn’t do this an hour or so ago.” He later brings a water cup directly to his lips with no tremor.
“This has really been my second epiphany in medicine,” says Baltuch. “My first in this field was when we saw the early deep brain stimulation videos.” Watching patients’ symptoms instantly disappear “was like magic,” he says. Witnessing patients discover their Parkinson’s tremors have vanished following a procedure, “is the same thing. When you see it, it’s phenomenal.”
Tremor In Other Conditions
While tremor is a common symptom of Parkinsons, it can also be a symptom of other conditions, most notably essential tremor. The main difference between Parkinsons tremor and most other types of tremor is that in Parkinsons resting tremor is most common. Other conditions are usually characterized by action tremor, which tends to lessen at rest and increase when youre doing something, like trying to make a phone call or take a drink.
Tremors of the head and voice are also common in essential tremor but rare in Parkinsons.
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How Is Parkinsons Diagnosed
Doctors use your medical history and physical examination to diagnose Parkinson’s disease . No blood test, brain scan or other test can be used to make a definitive diagnosis of PD.
Researchers believe that in most people, Parkinson’s is caused by a combination of environmental and genetic factors. Certain environmental exposures, such as pesticides and head injury, are associated with an increased risk of PD. Still, most people have no clear exposure that doctors can point to as a straightforward cause. The same goes for genetics. Certain genetic mutations are linked to an increased risk of PD. But in the vast majority of people, Parkinsons is not directly related to a single genetic mutation. Learning more about the genetics of Parkinsons is one of our best chances to understand more about the disease and discover how to slow or stop its progression.
Aging is the greatest risk factor for Parkinsons, and the average age at diagnosis is 60. Still, some people get PD at 40 or younger.
Men are diagnosed with Parkinsons at a higher rate than women and whites more than other races. Researchers are studying these disparities to understand more about the disease and health care access and to improve inclusivity across care and research.
Aging is the greatest risk factor for Parkinsons, and the average age at diagnosis is 60. Still, some people get PD at 40 or younger.
The Michael J. Fox Foundation has made finding a test for Parkinsons disease one of our top priorities.
Impact Of Tremor For Patients With Early Stage Parkinson’s Disease
Patients with early stage PD consistently rank tremor as highly important, even when asked to consider other diverse aspects of their condition. Tremor was cited as the most bothersome symptom in a survey of 75 PD patients with relatively mild symptom severity . Twenty-eight percent of patients mentioned tremor in their open-ended response to the question, Which two problems related to Parkinson’s disease bother you most?
The psychosocial impact of tremor for many PD patients is insidious and profound and goes well beyond a general annoyance . During an in-depth structured interview , patients and caregivers shared emotional and highly compelling stories of trying to disguise tremor during the early stages of PD by wearing clothes with pockets or hiding an affected hand behind one’s back. They went further to express dreading the progression of their tremor during later stages of PD with remarks such as, as it changes to slavering and trembling in a corner, I will find that a horror.
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The Clinical Phenotype Of Tremor
The classification of patients with Parkinson’s disease into tremor-dominant and non-tremor subtypes is well established. Different taxonomies have been used to define these two subtypes. First, tremor-dominant Parkinson’s disease has been contrasted with a form of Parkinson’s disease dominated by axial symptoms, i.e. postural instability and gait disability . This distinction is based on the relative expression of tremor and PIGD, using subscores of the Unified Parkinson’s Disease Rating Scale . Second, tremor-dominant Parkinson’s disease has been contrasted with a Parkinson’s disease subtype dominated by bradykinesia and rigidity , again using UPDRS subscores. A third, data-driven approach has identified Parkinson’s disease subtypes by applying clustering algorithms to several clinical parameters such as symptom severity, disease onset and clinical progression . The latter approach again produced tremor-dominant and non-tremor clusters of patients, together with a young-onset form and a rapid progression group.
Tremor is an Independent Symptom
Tremor is a Marker of Benign Parkinson’s Disease
What Is Tremor Dominant Parkinson Disease
Tremor dominant parkinsonism is characterized by initial prominent resting and action tremor, mild parkinsonism, unpredictable response to medication, and a better prognosis than idiopathic Parkinsons disease . We report on clinical features and longitudinal course of 26 patients suffering from TDP.
Fda Approves Focused Ultrasound For Tremor
Tremor-predominant Parkinsons disease joins Essential tremor as an FDA-approved indication for the use of Focused ultrasound. Focused ultrasound is a technology in which beams of ultrasound waves are focused on a designated target thereby concentrating enough energy to create a small lesion. When a lesion is created in very specific locations in the brain, it can disrupt the abnormal Parkinsons circuitry, thereby treating some of PDs motor symptoms.
Individual ultrasound waves do not contain enough energy to do any damage as they pass through a patients skull and brain tissue. It is not until multiple waves are all focused on a particular spot that a lesion is formed. In the recently approved procedure, MRI is used to precisely direct the ultrasound waves to an area of the thalamus, a structure deep in the brain that acts as a relay station for many of the brains functions. Abnormalities of thalamic circuitry are known to play a role in tremor and lesioning specific areas of the thalamus decreases tremor. Research of focused ultrasound in other brain regions continues to be explored as possible treatments for PD symptoms such as slowness and stiffness.
The device used to deliver this treatment is called Exablate Neuro and is a product of the company InSightec.
The Comparation Of Inflammatory Factors Between Pd
The levels of inflammatory factors, including IL-1, IL-6, PGE2, NO, and H2O2 in the CSF and serum were compared among the control, PD-PIGD and PD-TD groups . Further comparison of the inflammatory factors between the PD-PIGD and PD-TD groups of drug-naive patients could be seen in Supplementary Table 4.
In the CSF, the PD-TD group had significantly enhanced IL-6 levels compared with the PD-PIGD and control groups . In the serum, IL-6 levels in the PD-TD group were strikingly increased compared with the PD-PIGD and control groups . These results were consistent with the comparison of the inflammatory factors between PD-PIGD and PD-TD groups of the drug-naive patients .
Table 3. The levels of inflammatory factors in CSF and serum from the control, PD-PIGD and PD-TD groups.
Further analysis suggested that IL-6 level in the CSF had a positive and significant correlation with IL-6 levels in the serum .
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The Comparation Of Iron And Iron Metabolism
The levels of iron, ferritin, H-ferritin, L-ferritin, transferrin, and lactoferrin in the CSF and serum were compared between the control, PD-PIGD and PD-TD groups . Further comparation of the iron and its metabolism-related protein between the PD-PIGD and PD-TD groups of drug-naive patients can be seen in Supplementary Table 3.
Table 2. The levels of iron and its metabolism-related proteins in CSF and serum from the control, PD-PIGD and PD-TD groups.
In the CSF, iron levels in the PD-TD group were significantly higher than those in both the control and PD-PIGD groups .L-ferritin levels in the PD-TD group were prominently lower than those in the control and PD-PIGD groups . These results were consistent with the comparison of the above factors between the PD-PIGD and PD-TD groups of the drug-naive patients .
In the serum, ferritin level in the PD-TD group was strikingly lower than those in the PD-PIGD and control groups .
How The Innovation Works
One advantage of ultrasound is that it does not damage the tissue it passes through, yet focusing multiple waves on a targeted area produces heat, which can destroy, or ablate, the tiny area of the brain causing the tremors.
Finding a way to get ultrasound to penetrate the dense tissue of the skull and accommodate individual variability took years of development. INSIGHTEC, which was founded in 1999 and has dual headquarters in Haifa, Israel, and Miami, developed hardware that produced ultrasound powerful enough to penetrate the skull, and software that corrects for skull shape and thickness.
The technology often can use a facility’s existing MRI, Ferré says, which enables the neurosurgeon to guide the high-energy focused ultrasound waves. The procedure is known as MRgFUS and the treatment is an incisionless thalamotomy.
Patients are awake during the process and wear a special helmet that delivers the ultrasound treatment from inside the MRI machine. They typically start the session unable to drink water from a glass or write legibly because of tremors. Before the ablation occurs, the medical team does preliminary testing to ensure the proper brain location is pinpointed.
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